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        <p>2018年11月8日-11月9日，我参加了张东星老师在昆明的微创拔牙实战培训班。拔牙也是我心中的痛，经常拔一颗牙拔一两个小时。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/01.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/02.jpg"><br>总结一下吧。<br>拔牙不是多数医生的主流收入，但是能扩大客户群。牙医的核心竞争力还是技术。<br>患者主诉牙是7，先做7的治疗再拔8。防止纠纷。<br>最新版的教材是最好的。<br>阻生牙的分类<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/03.jpg"><br>分类的目的，选择患者。初学先拔高位的。<br>根据与邻牙关系<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/04.jpg"><br>根据阻生牙与第二磨牙及下颌升支前缘的关系<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/05.jpg"><br>下八远中有下颌骨，阻力大。可以分牙或去骨，制造空间，微创就是分牙而不去骨。<br>关于拔牙禁忌症<br>20岁以上建议量血压，60以上必须量血压。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/06.jpg"><br>放大一倍，一年以内有问题的，pass<br>心瓣膜病，术前2小时给抗生素(阿莫西林)，术后吃三天。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/07.jpg"><br>要有专科医生建议。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/08.jpg"><br>肾病别用肾脏代谢的抗生素。<br>糖尿病空腹血糖一定要在8以下。术前术后使用抗生素。原因是糖尿病人蛋白合成能力差。<br>甲亢麻药不能加肾。<br>经期拔牙出血多。<br>妊娠期全程不拔牙。<br>麻药哺乳期都可以用<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/09.jpg"><br>急性炎症期，酸性产物使麻药效果不好，毛细血管充血使出血多。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/10.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/11.jpg"><br>转诊不丢面子，转诊就是转移风险。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/12.jpg"><br>喷水柱，一定要喷在工作刃上。<br>排气向上或侧排。<br>要保证其同心性。<br>微创的基本原则，多分牙少去骨。<br>分牙别分到骨头。<br>超声骨刀对软组织无切割力。<br>涡轮机转速太快，有负压，会吸引粘膜。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/13.jpg"><br>直径3MM最好，1.5MM易堵。<br>没吸引器就用转接头，某宝上有。<br>拔牙车针建议用25mm的。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/14.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/15.jpg"><br>微创牙挺挺刃较薄<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/16.jpg"><br>只能用楔力，不能用杠杆力，只能增隙。<br>2MM一只，3MM一只<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/17.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/18.jpg"><br>1号 2MM<br>2号 3MM<br>3号 4.5MM<br>断根主要的原因，用力太大。先用小号，牙齿松动是逐渐的。<br>直挺力传递直接，手感好。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/19.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/20.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/21.jpg"><br>不用取出来的。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/22.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/23.jpg"><br>应该选3/8的缝针。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/24.jpg"><br>种植机分牙比较困难<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/25.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/26.jpg"><br>拔牙最主要是拔牙根<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/27.jpg"><br>如果根尖有条索状阴影，不在下颌管内。在下颌管内的比例7%，避免神经损伤，还是看外科技术。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/28.jpg"><br>损伤的情况主要在掏根的时候。<br>拔智齿5MM以下牙根可以不取。<br>拔智齿主要刮冠方牙槽窝，根尖区可以不刮。<br>预留牙根可能自行排异或牙根骨化。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/29.jpg"><br>cbct就好多了。<br>阻力分析<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/30.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/31.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/32.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/33.jpg"><br>去骨去多少？要暴露牙冠的最大周径，一般把牙冠露出2/3即可。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/34.jpg"><br>拔除设计<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/35.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/36.jpg"><br>垂直阻生的<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/37.jpg"><br>先试着挺，挺不动，远中分牙，解除远中骨阻力。<br>腾空间拔牙。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/38.jpg"><br>有牙囊影，在骨里<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/39.jpg"><br>近中阻生的，就必须分牙了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/40.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/41.jpg"><br>水平高位的<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/42.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/43.jpg"><br>术前难度评估<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/44.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/45.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/46.jpg"><br>局麻，先涂表麻，两根棉签，第一根擦干棉球，第二根涂表麻。苯佐卡因凝胶。<br>两分钟内注射<br>上颌8-8，下颌5-5，浸润就够了。<br>下颌5-8还是阻滞吧。<br>翻瓣的问题<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/47.jpg"><br>①舌侧组织太疏松，容易出血和术后肿胀。切1CM左右。<br>刀尖垂直切到硬组织，牙或骨组织。<br>②前庭沟上方1-2MM，切到黏骨膜，全厚瓣。<br>④翻瓣不要超过外斜线。下八可以在颊侧骨板做支点。<br>⑤切口范围应盖住牙槽窝。<br>⑥保证血供<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/48.jpg"><br>两种翻瓣方式：<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/49.jpg"><br>一定先做远中切口，再看是否需要做垂直切口。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/50.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/51.jpg"><br>尽量少去骨，暴露牙外形高点。<br>只去颊侧和远中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/52.jpg"><br>T形分牙，即先从牙颈部分牙，分了以后如果近中牙冠还是无法脱位，再沿近远中将近中牙冠的颊、舌侧分开，先用颊侧牙体做支点将舌侧牙体取出，再取颊侧牙体。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/53.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/54.jpg"><br>分牙后让牙根往前挺。<br>一定要冷敷，要吃止痛药，可以酌情给抗生素及激素等。<br>术后疼痛和干槽症的区别：前者麻药过了就疼，创口干净，后者拔牙后数天才开始疼。<br>一些技巧<br>去骨<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/55.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/56.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/57.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/58.jpg"><br>磨出一个槽放挺子就行，不要降低骨高度，半月形叠瓦状。<br>分牙技巧<br>分冠主要是解除邻牙阻力，分根主要解除根部阻力。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/59.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/60.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/61.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/62.jpg"><br>注意深度和角度的把控。<br>间断磨除。<br>分牙也有落空感。<br>挺不动牙根的，斜分牙根。<br>牙挺的使用技巧：使用牙挺分四种方式<br>挺：用挺刃的根方来接触要拔的牙齿，注意不要用邻牙做支点。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/63.jpg"><br>推法：冠部挺刃用力，只适用于远中邻牙缺失或位于牙列末端远中游离，有较大空间的牙。拔上8主要用推法。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/64.jpg"><br>楔法：挺刃与牙长轴平行。微创拔牙的方法。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/65.jpg"><br>撬法：主要是拔残根用。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/66.jpg"><br>残根拔不出来怎么办？把牙根分开，尽量分到根尖。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/67.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/68.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/69.jpg"><br>干槽症的问题<br>放射状，耳颞部都疼。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/70.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/71.jpg"><br>别刮了，反复擦洗。<br>不疼了，不建议持续换药。除去纱条后，观察牙槽骨壁是否长满肉芽组织，哪里没长满，再放碘仿纱条。<br>预防，别让唾液混到拔牙创，稳定血凝块，最好放胶原蛋白，缝合。<br>练习分牙<br>离体牙放到石膏里，分牙，不伤石膏<br>下牙槽神经阻滞麻醉失败或标志点不明显怎么办？<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/72.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/73.jpg"><br>手摸到下颌升支，从那进针2-2.5CM，到骨面，注射。<br>双回抽，注射后回抽，阴性再转一下注射器，再回抽。（防止针孔被血管膜堵住了，假阴性）</p>
<p>实操<br>两个人用一个猪头，在同学操作时我拍了过程。<br>先是张老师示教<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/74.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/75.jpg"><br>用的缝针缝线:<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/76.jpg"><br>刀片<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/77.jpg"><br>切龈，翻瓣，先从7远中开始切，往远中约2CM（人牙1CM左右），刀尖抵到骨面，然后试情况决定是否做近中切口，切口做到7近中，避开牙龈乳头，然后向前庭沟延伸，到龈膜联合就行了，太向下容易术后肿胀。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/78.jpg"><br>然后用涡轮机去骨，在颊侧，保持骨皮质高度，半月形去骨，暴露牙冠最大周径。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/79.jpg"><br>然后近中分牙，如果冠方不好操作，从颊侧开始分，一定要磨到深度，不要只磨一点就用梃子撬。当然也不能太深磨到牙冠下的牙槽骨了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/80.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/81.jpg"><br>分完用梃子伸进去撬，牙齿就分开了。再做T形分牙，从分牙间隙那里由远中向近中将近中牙冠分为两半，再用梃子撬开。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/82.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/83.jpg"><br>先把舌侧的牙体撬出来，再撬颊侧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/84.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/85.jpg"><br>这样近中部分牙体就拔完了，该拔远中部分了。先用梃子挺一下试试，挺不动，就用拔牙车针斜向分根，具体做法是从颊侧放入车针，在正中央的地方开始磨（对了，分牙，去骨，都是把车针位置放好再踩，不是车针转着放进去。)，这样就一定是斜着磨的。把舌侧牙体磨开。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/86.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/87.jpg"><br>用梃子掰断舌侧牙体，取出，最后挺出颊侧牙体。注意，这个时候要用撬的力从远中往近中撬出牙根，而不能用挺的力，否则很容易对牙根施加向下的力，压迫下颌管，导致神经损伤。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/88.jpg"><br>拔完以后。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/89.jpg"><br>搔刮主要搔刮冠方，牙根区域不要过度搔刮。<br>牙槽窝内可以放胶原蛋白塞。<br>缝合<br>先缝远中切口，在7远中邻面的地方缝第一针，一个细节是打完结以后带着针的线长的那一端不要用力牵拉，结就不会松了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/90.jpg"><br>第二针在第一针和远中切口最远处之间的中间，跟第一针一样的方法。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/91.jpg"><br>完了要使切口对齐。<br>接下来封第三针，在7近中垂直切口中央缝。有个技巧，如果按常规方法夹持缝针，口腔会挡住持针器，这时可以将缝针向8的方向旋转一个角度，斜着夹缝针，用执笔式握持持针器，就容易进针了。进针以后再按常规方法夹针就行了。看张老师示教。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/92.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/93.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/94.jpg"><br>最后，如果沟内切口和垂直切口之间的组织有撕裂等情况，可以加一针悬吊缝合，方法是从撕裂处进针，针头通过67间，不穿过颊侧龈乳头，然后直接从67舌侧龈乳头下方穿出，再让缝线像牙线那样穿过67邻间隙，在颊侧打结。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/95.jpg"><br>接着还拔了一颗2，主要是体验微创拔牙，主要就是用微创挺往下楔，360°的楔（人主要在近中和远中楔，而且最好片切以后再楔，防止损伤邻牙），楔入牙根长的2/3以后，很容易拔下来的。楔的时候手法是挺的把手抵住掌心，垂直用力。猪牙那么长啊。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/96.jpg"><br>半天实操，结束后下午还有半天理论，讲拔正畸牙，种植拔牙等，就不赘述了。<br>两天课听下来感觉还是蛮有收获的，其实讲的理论书上大部分都有（大多数课程都是这样的，所以别期望听了一次课，尤其是付费的课就能怎么怎么样，关键是老师的思路和方法，要真正掌握，系统学习和练习是别人代替不了你的。），但是张老师在讲课和实操过程中讲了很多临床细节和技巧，很有帮助。<br>两天课最核心的内容：微创拔牙就是多分牙，少去骨。<br>继续努力，接下来继续整理我的根管的内容。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/97.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/98.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0053-zdxbab/99.jpg"></p>
<p>这篇文章就是在kq88上被删了，导致我想自己建博客的那篇博文。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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